Catastrophic Health Expenditure from Surgery in Ethiopia: A National Assessment of Financial Risk

Catastrophic Health Expenditure from Surgery in Ethiopia: A National Assessment of Financial Risk

Emilia B Ferreira, Ermiyas Belay, Fitsum Kifle, Tesfay Yohannes, Kalkidan Kifle, Peniel Kenna, Elise Presser, Taylor Jaraczewski, Fay Abu-Hamdan, Chris Dodgion, Andualem Beyene, Katherine R. Iverson
Medical College of Wisconsin, Wauwatosa, United States; Network for Perioperative and Critical Care, Addis Ababa, Ethiopia; Yale University, New Haven, United States; Black Lion Hospital, Addis Ababa, Ethiopia

Introduction
Access to surgical care in Ethiopia, a low-income country in East Africa, is limited by financial barriers and resource availability. Catastrophic health expenditure (CHE), defined as out-of-pocket costs exceeding 10% of annual household expenditure, is a key global metric for assessing surgical access. This study aimed to estimate national burden of CHE among surgical patients and identify associated risk factors.

Methods
A total of 412 patients from 32 hospitals across all 14 regions of Ethiopia were enrolled. Surveys were administered at discharge to patients to assess out-of-pocket spending among those undergoing surgery during hospitalization. The primary outcome was the proportion of patients whose direct medical costs exceeded 10% of their annual household expenditure. Data were analyzed using descriptive statistics and multivariate logistic regression.

Results
Among 412 patients (53.6% female), 103 (25.0%) experienced CHE. Key predictors included being unmarried (OR=0.38, p=0.002), smaller household size (<5 members: OR=0.52, p=0.046) and trauma-related surgery (OR = 1.95, p = 0.042). Medications constituted the largest expense at 3,536 birr (~$60) or 40.4% of total direct medical costs. Patients borrowed money in 16.6% of cases to afford care.

Conclusion
One in four of surgical patients in Ethiopia faced catastrophic expenditure, reflecting major financial vulnerability and risk of impoverishment due to surgery. These findings underscore the urgent need for policies that enhance financial protection and expand access to safe affordable surgical care.

Keywords: Catastrophic health expenditure, surgical access, financial protection, out-of-pocket costs, global surgery, Ethiopia